ARBOVIRUS CASE INVESTIGATION FORM
Today’s date: Day______/Month_____/Year______
Puerto Rico Public Health Laboratory, Department of Health
Check suspected arboviral infection (Check all
Building A – Second Floor, Medical Center Area
that apply):
Dengue
Zika
P.O. Box 70184, San Juan, PR 00926
Tel. (787)765-2929 ext. 3728, Fax (787) 274-5710
Chikungunya
Other __________________
Please read and complete ALL sections. See instructions on back page.
1. Patient Data
Hospitalized due to this illness: No
→ Hospital Name:
Yes
Record Number:
Fatal:
Name of Patient:
Last Name
First Name
Yes
Middle Name or Initial
If patient is a minor, name of father or primary caregiver:
Last Name
First Name
2. Patient’s Home (Physical) Address
Unk
Middle Name or Initial
Yes
No
Unk
5. Physician contact information
Physician who ordered test - Name:
Housing Development/Building:
Home address here
No
Mental status changes:
National Provider Identifier (NPI):
Number:
Tel:
Street:
City:
Street:
City:
Other Tel:
Zip code:___ ___ ___ ___ ___ - ___ ___ ___ ___
Residence is close to:
Hospital/Clinic/Laboratory:
Work address:
Primary care doctor- Name:
3. Patient’s Demographic Information
Date of Birth:
Age:
month Sex:
_______/_______/_______ or Age:
Day
Month
years
M
F
Pregnant: Y
N
UNK
4. Patient Symptom Status and Onset/Date of Specimen
Yes
No
Day
If symptomatic, date of first symptom(s):
Tel:
Fax:
Mailing address:
Email:
Number:
Street:
City:
Estimated Date of Delivery: Day_____/Month______/Year_____
Patient symptomatic?
Specialty:
National Provider Idenifier (NPI):
Weeks pregnant (gestation):
Year
Email:
Mailing address: Number:
Zip code: __ __ __ __ __ - __ __ __ __
Tel:
Fax:
Month
Year
Zip code: ___ ___ ___ ___ ___ - ___ ___ ___ ___
Hospital/Clinic/Laboratory:
Specialty:
6. Who filled out this form?
Name:
Relationship with patient:
_______/_______/_______
Date specimen taken:
Serum sample
_______/_______/_______
Other sample (Specify type:____________________)
_______/_______/_______
Other sample (Specify type:____________________)
_______/_______/_______
Other sample (Specify type:____________________)
_______/_______/_______
Tel:
Fax:
Email:
7. Additional Patient Data
Country of birth:
During the 14 days before onset of illness, did you TRAVEL to other municipalities, or countries?
Yes, another country
Yes. another municipality
No
Unknown
Where did you Travel? ________________________________________________________________
8. Description of patient’s signs and symptoms experienced at time of form completion
Yes
No
Unk
Symptoms
Yes
No
Unk
Warning signs
Rapid, weak pulse……………...
Persistent vomiting...................................
Pallor or cool skin……………….
Abdominal pain/Tenderness…………..
Chills………………………….……
Mucosal bleeding …………………….....
Rash…...........................................
Lethargy, restlessness……….…………...
Platelet count: ______________________________
Headache……………….……….
Liver enlargement >2cm………………..
Any hemorrhagic manifestation
Eye pain…………………………..
Pleural or abdominal effusion………….
Fever lasting 2-7 days……………......
Fever now(>38ºC)…………………......
Platelets ≤100,000/mm3………..….....
Petechiae………………………..
Body (muscle/bone) pain…….
Purpura/Ecchymosis…………..
Joint pain…………………………
Diarrhea……………………………...……..
Vomit with blood……………….
Anorexia……………………….....
Cough…………………………………….…
Encephalitis/Meningitis………
Conjunctivitis……………………………....
Blood in stool……………………
Nasal bleeding…………………
Blood in urine…………………...
Sore throat………………………………....
Intracranaial calcifications..….
Vaginal bleeding………………
Jaundice………………………..................
Other birth defect(s)…………….
Positive urinalysis……………....
Specify____________________________________________
(over 5 RBC/hpf or positive for blood)
Mother with positive or
Pos
Neg
Convulsion or coma……………………..
Nausea and vomiting (occasional)…..
Arthritis (Swollen joints)……....................
indeterminate Zika test results....
Not done
Unk
Nasal congestion…………………………
Microcephaly……………………
Tourniquet test
No
Additional symptoms
Infant (only)
Bleeding gums………………….
Yes
9. For laboratory use
Case number
SAN ID
PRDOH REV. 2/2016
Specimen #
GCODE
Days post onset (DPO) Type
Date Received Specimen #
Days post onset (DPO)
Type
Date Received
S1
_____/_____/_____ S3
_____/_____/_____
S2
_____/_____/_____ S4
_____/_____/_____
FOR PUERTO RICO DEPARTMENT OF HEALTH USE ONLY
10. Barcode
Instructions for filling out Arbovirus Case Investigation Form
General instructions: The recently amended Law 81 of 1912 establishes that dengue infection, dengue hemorrhagic fever, chikungunya infection, and Zika
infection are reportable diseases to the Puerto Rico Department of Health. The health provider will write text responses in print lettering and will send this
form with the patient for laboratory testing. The form should be submitted with the laboratory sample to be tested. Please fill out all sections. If sections 1–5
are not completed, the sample will not be processed!
Upper left corner of the form:
Write the date (day, month, year) on which the report was completed.
Indicate which arboviral infections are suspected . Mark all that apply
Section1. Patient Data:
Check “Yes” or “No” to indicate if the patient was hospitalized due to this illness. If the patient was hospitalized, write the name of the hospital and
medical record number.
Provide full name of patient and full name of father or primary caregiver if patient is a minor.
Write the name and surnames of the patient in the following order: paternal and maternal surnames, first name and middle name or initial.
If the patient is a minor, write the name of the parent or primary caregiver. Please, write the surnames first and then the first name.
Check if the patient died or not. If you do not know this information, check “Unk” for unknown.
Check if patient presents or does not present mental status changes as such changes may be associated with encephalitis.
Section 2. Patient’s Home Address: This information allows the PRDOH to follow-up on the patient and to take vector control measures as needed.
If the patient lives in an urban area, write the name of the area, street name or number, block and house number, city/town where patient resides, and
ZIP code + 4 digits.
If the patient lives in a suburb, print the road number, kilometer, house or premise number, county, sector, city/town where patient resides, and ZIP code
+ 4 digits.
If the patient lives in a condominium or public housing, write apartment number, building, name of condominium or housing complex, street, city/town
where patient resides and ZIP code + 4 digits.
Write the patient’s phone number and an alternate phone number where we could contact the patient.
Indicate a reference point close to the patient’s home (Example: next to Rivera’s Grocery Store).
If the patient has a job, write the name of the employer, including street or sector and city/town.
Section 3. Patient’s Demographic Information:
Write the date of birth of the patient (day, month and year, in that order).
Indicate age of the patient. Write the age in months if the patient is an infant or in years if older than 1 year of age.
Check the “M” box for male or “F” for female.
Check “Yes”, “No” or “Unknown” regarding patient’s pregnancy status; if pregnant, note gestational age in weeks and estimated date of delivery.
Section 4. Patient Symptom Status and Onset and Date of Specimen.
Note if patient is symptomatic. This will help the lab determine which type of laboratory test to use.
Note day, month, and year of first symptom.
Note day, month, and year samples were taken and specify type of sample (blood, urine, cerebrospinal fluid, etc., or renal, splenic, or heart tissue, etc.)
Section 5. Physician contact information: This contact information is critical, as by law, results will only be mailed to the service provider!
For the physician who ordered the test, write the physician’s name, National Provider Identifier (NPI) number, telephone and extension numbers, fax,
email, mailing address, name of hospital, clinic, or laboratory, and specialty. The NPI number can be obtained at https://npiregistry.cms.hhs.gov/ .
For the primary care doctor or obstetrician, if different from the physician who ordered the test, write the same information. The results will only be
shared with this (these) provider(s). It is especially critical that the obstetrician receive a pregnant woman’s results.
SUPPLEMENTAL INFORMATION
Section 6. Who filled out this form?
Write the complete name of the person filling out the form.
Indicate your relationship with the patient (e.g.: mother, father, primary caregiver, neighbor, physician, nurse).
Write the phone number, fax or e-mail address.
Section 7. Additional Patient Data
Specify country of birth.
If the patient traveled to other countries or municipalities 14 days before beginning of symptoms, check “Yes, another country” or “Yes, another
municipality”. If the patient did not travel, check “no”, or doesn’t remember, check “Unk” if unknown. If the patient traveled, specify country or
municipality visited by the patient 14 days before beginning of symptoms.
Section 8. Description of patient’s signs and symptoms experienced at time of form completion.
Check (√) the boxes to mark “Yes,” “No,” or “Unk” for each question related to symptoms. Please answer all questions.
In the blank provided indicate platelet count.
For infants only (not fetuses), mark “Yes,” “No,” or “Unk” related to whether infant had microcephaly, intracranial calcifications, or other birth defect
(please specify which other birth defect) or if the infant’s mother had positive or indeterminate Zika test results while pregnant.
Sections 9 and 10. Do not complete these sections. For laboratory use only.
PRDOH REV. 03/2016